KENNETH L. WILSON, MD, FACS DIRECTOR OF PEDIATRIC TRAUMA ASSISTANT - - PowerPoint PPT Presentation

MANAGEMENT OF PEDIATRIC PENETRATING TRAUMA

KENNETH L. WILSON, MD, FACS DIRECTOR OF PEDIATRIC TRAUMA ASSISTANT PROFESS OF SURGERY MICHIGAN STATE UNIVERSITY, COLLEGE OF HUMAN MEDICINE

HAPPY HUMP DAY!

Woop Woop!!

KINETIC ENERGY

• Ke= (1/2)MV2
• Energy is transferred from the missile

to the tissue

• Speed Kills!

HIGH VELOCITY GSW

• Tissue is stretched by

a temporary cavity

• Higher velocity

missiles cause greater cavitations

• Higher velocity

missiles produce greater energy waves

Emergency War Surgery, 3rd Edition

KE= (1/2)MV2

ABDOMINAL TRAUMA: ANATOMIC ISSUES

Larger solid organs, less musculature, compact torso, elastic ribcage, liver & spleen anterior

–  Potential internal injury – Spleen>liver>kidney> pancreas>intestine

Bladder intra-abdominal

– 10% have GU injury

HIGH VELOCITY GSW INJURY

DAMAGE CONTROL PROCEDURE

20 YEARS OF PEDIATRIC GUNSHOT WOUNDS

• 740 patients (ages 0-16) at University of Miami between 1991

to 2011

• 82% male; African American (72%)
• Most frequently were shot in the abdomen, back or pelvis
• Patients with head or neck injuries experienced the highest

mortality rate (35%)

• The mortality rate overall was 12.7%

Davis JS et al. Journal of Surgical Research, 2013.

10/7/1991– 9/29/1995 9/30/1995– 9/21/1999 9/22/1999– 9/14/2003 9/15/2003– 9/7/2007 9/8/2007– 8/30/2011 ∗ P value

244 175 87 95 139

Anatomic location Abdomen/bac k/pelvis 71 (29%) 54 (30%) 33 (38%) 20 (21%) 19 (14%) < 0.001 Chest 42 (17%) 28 (16%) 18 (21%) 14 (15%) 6 (4%) 0.003 Extremities 28 (11%) 25 (14%) 13 (15%) 21 (22%) 52 (37%) < 0.001 Face/head/ne ck 79 (32%) 43 (25%) 16 (18%) 21 (22%) 12 (9%) < 0.001 Multiple 24 (10%) 25 (14%) 7 (8%) 19 (20%) 32 (23%) < 0.001

Twenty years of pediatric gunshot wounds: an urban trauma center’s experience

Davis JS et al. Journal of Surgical Research, 2013.

20 YEARS OF PEDIATRIC GUNSHOT WOUNDS

• Data indicate a decrease in total number of firearm injuries

from 1991 through 2003.

– Youth drug and violence prevention programs – Improved gun control, gun safety educational programs, – More austere prison sentences – Decline in the cocaine trade

• The gradual increase include deteriorating police

effectiveness, greater access to guns, and decreasing investment in educational and deterrent programs

DIAGNOSTIC EVALUATION

• ABI’s should be performed
• Evaluate for hard signs of vascular injury (bleeding,

expanding hematoma, bruit, etc.)

• In absence of hard signs

– Duplex ultrasound – CTA – On-table angiogram

• Equivocal findings or abnormal findings warrant surgical

exploration

ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS

• Smaller arteries prone to vasospasm
• Small intravascular volume
• Low intravascular volume can contribute to

vessel thrombosis

• 12% of femoral vessels in children aged 0 to 9

are partially or completely overlapping

CHALLENGES IN PEDIATRIC VASCULAR TRAUMA

• Two thirds of injuries are noniatrogenic in children older than 6

years

• Half or more are caused by penetrating injuries
• Femoral artery disruption can be associated with limb length

discrepancy which may not manifest until several years after the vascular insult

CHALLENGES IN PEDIATRIC VASCULAR TRAUMA

• Historically injured vessels were managed with ligation

– Stunted limb growth – High amputation rates

• Severe persistent vasospasm (lasting hours)

– Once series found a 26% incident of peripheral arterial vasospasm that ultimately resolved without vascular reconstruction* – ABI of 0.88 can be “normal” in children younger than 2 years of age * Noniatrogenic pediatric vascular trauma. J Vasc Surg, 1989.

SWEDVASC

• Prospective study; children 15 years or younger from 1987 to 2013
• There were 222 operative procedures
• Anatomic locations were primarily upper extremity

– Upper extremity (n =134, 60%); brachial artery most dominant – Lower extremity (n = 29%); Popliteal second most common – Abdomen (n = 16, 7.2%)

Wahlgren et al. Management and outcome of pediatric vascular injuries, J Trauma Acute Care Surg, 2015.

SWEDVASC

• Interposition graft (n = 54, 24%)
• Patch (n = 43, 19%)
• Lateral suture/direct anastomosis (n = 27, 12%)
• Bypass (n = 21, 9.5%)
• Endovascular techniques (n= 8, 3.7%)

– 4 patients (ages 2-6) had stents placed in axillary, subclavian, external iliac and thoracic aorta

• No vascular reconstructions performed in patients less than 2

years of age

SWEDVASC

• Arterial occlusion/thrombosis most common complication (n= 12)
• 30-day follow-up; one BKA and one AKA
• Mechanism of injury dominant with injuries located primarily in the upper

and lower extremities

• Vascular injuries in children associated with high limb salvage

Wahlgren et al. Management and outcome of pediatric vascular injuries. J Trauma Acute Care Surg, 2015.

WARTIME VASCULAR INJURIES

• (DoDTR) (2002-2011) identified patients (1-17 years old)

treated at US military hospitals in Iraq and Afghanistan for vascular injury

• U.S. military hospitals treated 4,402 pediatric patients; 150 pts

(3.5%) had a vascular injury

• Vascular injuries were primarily from penetrating mechanisms

(95.6%; 58.0% blast injury)

• Anatomic locations: Extremity (65.9%), torso (25.4%), and

neck (8.6%)

Villamaria CY et al. J Pediatr Surg, 2014.

PENETRATING (SECONDARY)

Unprotected torso Extremity Eye Head/neck Penetrating (fragments and debris)

Responsible for wounding

IEDS

Oil Can Tank Buster

WARTIME VASCULAR INJURIES

• Vascular injury rate of 3.5% higher than 0.6% in civilian

injuries

• Extremity injuries most common wounding pattern
• Torso vascular injuries primary source of mortality
• Injuries were reconstructed (63%), ligated (31%) or observed

(2%)

• Traditional vascular repair no different than civilian and

military adult populations

• TVS used in children were reported with no acute

complications

Villamaria CY et al. J Pediatr Surg, 2014.

TEMPORARY VASCULAR SHUNTS

• Both military and civilian experience show patency rates

between 85% and 95%

• TVS do not negatively affect limb salvage rates when used in

proximal vessels

• Distal TVS have poor patency rates and do not improve limb

salvage

• Should be used a bridge to definitive repair in injuries

requiring ongoing resuscitation

• Similar approaches appropriate in pediatric population

Cannon JW et al. Vascular injuries in the young, perspectives in vascular surgery and endotherapy, 2011.

WARTIME VASCULAR INJURIES

• Limb salvage rates was 95% combining both theaters of operation

consistent with civilian pediatric trauma

• Mortality rate was 9%
• Torso vascular injury in children is four times lethal relative to other injury

patterns

Villamaria CY et al. J Pediatr Surg, 2014.

Known Cause of Injury Age Location Injury Procedure Second Procedure IED 8 Head Brain Debridement YES IED 12 Extremity Femoral A Shunt, SFA Repair YES IDF 7 Abdomen/Chest Liver Liver Resection NO IDF 4 Abdomen Bladder Bladder Repair YES IDF 6 Abdomen IVC/Iliac V Ex Lap DIED IED 16 Chest Pulmonary Hilum Pulm Resection DIED VBIED 16 Abdomen Renal Nephrectomy YES IDF 7 Abdomen/Chest Duodenum Duodenal Repair YES VBIED 16 Extremity Femoral A/V Shunt, SFA Repair YES IED 13 Abdomen/Chest Lung/colon Colectomy NO

INTRACRANIAL GUNSHOT WOUNDS

EPIDEMIOLOGY OF GSW HEAD

• Likely to know the perpetrator
• Likely to be killed in the home by an

unsecured firearm

• Likely to die of a severe head injury

INTRACRANIAL GUNSHOT WOUNDS

• Pediatric population 1.31 deaths per 100,000 in 2004-

2008

• 1.42 deaths per 100,000 in 2004-2010
• Adult mortality ranges between 50% and 90% in most

series

• Children typically have a lower overall mortality when

compared to adults

• A greater propensity for neurological recovery

INJURY PATTERN PREDICTIVE OF DEATH

• GCS < 5 and dilated pupils
• Laboratory (initial hematocrit < 30%, base deficit < -5 mEq/L)
• Imaging (deep nuclear/3rd ventricular injury, bi-hemispheric

injury, intraventricular injury)

• At age less than 9 years, initial ICP > 30 cm H20, both supra-

infratentorial injury and midline shift were not predictive

• Coagulation (INR > 1.5) was not significantly associated with

death

Pediatric intracranial gunshot wounds: the Memphis experience. J Neursurg Pediatr, 2016.

MEDICAL AND SURGICAL MANAGEMENT

• ICP less than 20 cm H20
• Maintain CPP above 40-60 mm Hg
• Utilize fluids or vasopressors to adjust MAP and CPP
• Barbiturate coma
• Decompressive laparotomy

DECOMPRESSIVE LAPAROTOMY

• Basic science and limited clinical evidence suggests a close

relationship between intracranial and intra-abdominal pressures

• Proposed mechanism is decreased jugular venous outflow

from increased central venous pressure

• TBI with refractory intracranial hypertension following a

massive transfusion might be improved after laparotomy for abdominal compartment syndrome

Effects of increased intra-abdominal pressure upon intracranial and cerebral perfusion. J Trauma. 1996

ICP

IAP

PP CVP

INTRACTABLE INTRACRANIAL HYPERTENSION

• 17 patients with severe TBI and elevated IAP had successful

lowering of ICP by decompressive laparotomy

– Decompression completed after aggressive medical management – 13 patients treated with barbiturate coma

• None of the patients had extracerebral organ dysfunction to

suspect IAH/ACS

• Mean decompression IAP of 27.5 mmHG
• 11 of the 17 patients survived to hospital discharge

Joseph DK et al et al. J Trauma. 2004

DECOMPRESSIVE LAPAROTOMY FOR REDUCTION OF INCESSANT INCREASED INTRACRANIAL PRESSURE IN THE ABSENCE OF ABDOMINAL COMPARTMENT SYNDROME ARMANIOUS, M, WILSON KL ET AL.

NEUROLOGIC RECOVERY

PENETRATING NECK INJURIES

WORK-UP OF NECK INJURIES (STABLE)

• CT scan/CT angiogram is the an accurate primary test
• CT scan is extremely accurate in determining missile trajectory and depth of

penetration – Determines if other subsequent studies are required

• Inaba et al. demonstrated in an adult population 100% sensitivity and 93.5%

specificity.

PENETRATING NECK TRAUMA

• NTDB queried from 2008-2012 (pts < 15 years of age)
• 1,238 pts with penetrating neck injuries; incidence of 0.28%
• Majority male (70.6% n= 874); mean age 7.87 years
• Most common mechanism of injury was stabbing (44%, n =

546)

• Second most common gunshot/firearm (24%, n = 301)
• Only 243 operative neck procedures
• 69 patients died (mortality rate of 5.6%)

Penetrating neck trauma: an uncommon entity, J Trauma Acute Care Surg, 2016.

NTDB DATA

• CT Scan most frequent study performed (42.2%)
• Aerodigestive injuries were the most common and occurred

more frequently in the youngest age group (0-5 years)

• Operative procedure for aerodigestive group most common
• Vascular injury and hypotension independently associated

with mortality

• Overall mortality was 5.6%

ED THORACOTOMY

• Rarely life-saving for patients in extremis
• Associated with significant blood loss

– Increased prevalence of exposures for providers

• Associated with excessively high healthcare costs

– $100,000 or more per patient

• Significant portion of survivors have significant neurologic

impairment

A 40-YEAR REVIEW

• 1691 pts evaluated for age ≤ 18 years; included 179 pts (11%)

– Pediatric (age ≤15 years) – Adolescents (16-18 years)

• Pediatric patients more likely to sustain blunt injury (72% vs

32%)

• The youngest survivor of EDT was 16 years old
• All survivors had cardiac activity in the field

– Most common injury pattern was penetrating stab wound to the chest

Moore BM et al. Journal of Pediatric Surgery, 2015.

40 YEAR REVIEW: PEDIATRIC AGE GROUP

• There were no survivors in the pediatric age group
• Adolescent patients more frequently undergo EDT per year

compared to pediatric patient

• The rate of pediatric EDT was 1.3 per year
• A 10 year experience in the state of Illinois the rate was 2.3

EDT/year

ILLINOIS THORACOTOMY DATA

• Resuscitative thoracotomy was most frequent use for

penetrating trauma

– (n = 19, 76%)

• Males > Females (n = 19 boys; n = 6 girls)
• 83% of pediatric patients who received resuscitative

thorarocotomies were in extremis presenting with zero SBP

• 6 patients (24%) undergoing the initial resuscitative

thoracotomy survived

• Only 2 patients (8%) survived to discharge

Nicholson NG et al. American Journal of Surgery, 2015.

CONSIDERATIONS FOR PEDS EDT

• ED resuscitative thoracotomies rarely performed in the

pediatric population

• EDT for patients under the age of 15 is a futile procedure
• Not enough patients survived to draw a conclusion about

which patients are most likely to benefit from the procedure

• Dismal survival for blunt trauma pediatric patients
• Cautious not to over utilize resuscitative thoracotomy when

unlikely to benefit the patient

WHAT'S OLD IS NEW AGAIN

• Whole Blood use

– Effectively restore circulating volume – Provides oxygen carrying capacity – Carries vitally important clotting factors – Has buffering capabilities

• OIF/OEF balanced resuscitation with

platelets, plasma and packed red blood cells used effectively resembling whole blood

Glassberg E et al. J trauma Acute Care Surg. 2013

RBC-TO-FFP RATIO

• Borgman, MA et al. The ratio of blood

products transfused affects mortality in patients receiving massive transfusion at a combat support hospital (J Trauma. 2007)

• Perkins JG et al. An evaluation of

apheresis platelets used in the setting of massively transfused trauma patients (J

• Trauma. 2009)
• Both studied demonstrated a significant

survival benefit for massively transfused patients when the RBC:FFP:Platelet ratio is close to 1:1:1

Francisco R et al. The Armed Services Blood Program: Blood Support to combat casualty care 2001 to 2011. J Trauma Acute Care Surg. 2012 The Armed Services Blood Program: Blood support to combat

Rentas, Francisco; Lincoln, David; Harding, Aaron; Maas, Peter; Giglio, Joseph; Fryar, Ronny; Elder, Kathleen; Fahie, Roland; Whitlock, Kathleen; Vinluan, Jerome; Gonzales, Richard Journal of Trauma and Acute Care

• Surgery. 73(6) Ten Years of Combat

Casualty Care, 2001-2011:S472-S478, December 2012.

BALANCED BLOOD COMPONENT RESUSCITATION

• DOD Trauma Data Base 1,311 injured children < 14

years requiring transfusion

• All patients were treated in Afghanistan or Iraq 2002-

2012

• Purpose of the study: Effect of crystalloid volume and

balanced component resuscitation

The effects of balance blood component resuscitation and cryrstalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. J Trauma Acute Care Surg. 2015

BLOOD TRANSFUSIONS

• High Volume (>40

mL/kg)

• 224 pts
• Higher mortality (19%)
• Crystalloid resuscitation

– (+) association with increased ICU and ventilator days

• Age less than 4,

penetrating mechanism, ISS >15

• Massive Transfusion

(>70 mL/kg)

• 77 pts
• Mortality (25%)
• Crystalloid resuscitation

– (+) association with increased ICU and ventilator days

• ISS >15, severe

abdominal and severe extremities

. 2 The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. Edwards, Mary; Lustik, Michael; Clark, Margaret; Creamer, Kevin; Tuggle, David Journal of Trauma and Acute Care Surgery. 78(2):330-335, February 2015.

Effect of crystalloid administration on mortality

3

Effects of Blood Transfusion ratio on mortality

The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. Edwards, Mary; Lustik, Michael; Clark, Margaret; Creamer, Kevin; Tuggle, David Journal of Trauma and Acute Care Surgery. ,ebruary 2015.

BALANCED BLOOD COMPONENT RESUSCITATION

• Heavy reliance on crystalloid has an adverse effect
• n outcomes
• Balanced component resuscitation was actually

associated with higher mortality when all transfused patients were considered

• Clear trend toward increased mortality in both

groups when crystalloid > 150 mL/Kg

Edwards MJ et al. J Acute Trauma, 2015.

TRANEXAMIC ACID

• (TXA)

– Antifibrinolytic agent (synthetic lysine) – Prevents activation of plasminogen to plasmin

• Ongoing research needed in Peds
• Dosing recommendations exist

– 15-mg/kg (loading dose) – 2 mg/kg ( 8 hours or until bleeding stops)

PEDIATRIC TRAUMA AND TRANEXAMIC ACID STUDY (PED-TRAX)

• The only predictor of TXA use were severe abdominal or

extremity injury

• No significant thromboembolic complication
• Suggested improvement in neurologic status and decreased

ventilator dependence

• TXA administration was independently associated with

reduced mortality

Eckert, MJ et al. J Acute Trauma et al. 2014.

PEDIATRIC MASSIVE TRANSFUSION PROTOCOLS

• Military experience using

pediatric data from 2001 to 2013 seeking to find a data-driven MT protocol for Peds casualties

• Crystalloid resuscitation

had adverse outcome

• No benefit from

PRBC/FFP 1:1 ratio

• 40ml/kg of blood

products during MTP gave best results

• TXA given early

SUMMARY

• A survival benefit is not always seen in plasma-first

resuscitation, but adherence to damage control resuscitation in the prehospital setting will lead to an eventual mortality benefit

• Limited Volume resuscitation achieves best result; high

volume less good, and no-fluid resuscitation is worst option

• TXA appears to be the best pharmacologic agent for

hemostasis in a prehospital setting